Robotic-Assisted Treatment of Aberrant Retroesophageal Right Subclavian Artery

Aberrant right subclavian artery (ARSA) is a rare anomaly but is the most common congenital abnormality of the aortic arch with an incidence of 0.3-3.0% (1, 2). The vessel embryologically is the 4th branch of the aortic arch, most commonly passes behind the esophagus and crosses the midline between the esophagus and the vertebral column to reach the right arm (3). Approximately 60% may be aneurysmal at their origin (4). An aberrant right subclavian artery may be asymptomatic or can produce dysphagia (dysphagia lusoria), chest pain, shortness of breath or chronic cough.

Treatment of ARSA is indicated for symptomatic relief and for the prevention of aneurysmal dilatation and complications resulting from the aneurysm (5). Surgical treatment usually involves division of the subclavian artery at its origin. The classic approach involves a left thoracotomy (6) although other surgical approaches have been described including right thoracotomy (7), right-sided supraclavicular incision (8), and hybrid procedure with thoracic endoluminal graft exclusion (9). Recently robotic assisted resection has been described (10).

Restoring pulsatile blood flow to the right arm has been debated. Some advocate that revascularizing the subclavian artery is imperative (9). A published review demonstrated only 14% of patients who did not undergo revascularization following surgical treatment of ARSA developed limb ischemia (11). A case report demonstrated a patient did well without revascularization with intermittent weakness and numbness of his right arm until his death 11 years later (12).

This video demonstrates the technique of robotic assisted division of an aberrant retroesophageal right subclavian artery utilizing a right-sided approach. The patient is a 37-year-old with a history of chest pain and dysphagia. CTA of chest demonstrated an aberrant retroesophageal right subclavian artery (ARSA). The esophagus was effaced at the level of the vessel. The left subclavian had its origin near the right subclavian, and it was felt that endoluminal graft exclusion of the right subclavian artery could not be accomplished without also excluding the left subclavian. The aberrant right subclavian artery was stapled at its origin freeing the entrapped esophagus. The right arm was not revascularized. The patient was discharged home on the 1st postoperative day. Follow-up demonstrated a warm right arm with a weak right radial pulse. There was intermittent right arm fatigue, but no paresthesias. The patient’s dysphagia had completely resolved. CTA on follow-up demonstrated flush division of the right subclavian artery with excellent collateral flow to the subclavian and vertebral arteries. There was no esophageal narrowing or effacement. The right-sided approach offered excellent exposure of the aberrant artery allowing division at its origin from the aorta. In addition, the robotic approach offers improved vision and a stable platform resulting in reduced pain, hospital length of stay and enhance patient recovery time.

References

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2. Kieffer E, Bahnini A, Koskas F. Aberrant subclavian artery: surgical treatment in thirty-three adult patients. J Vac Surge 1994; 19:100-9.
3. Van Son JA, Konstantinov IE, Burckhard F, et al. Kommerell and Kommerell’s diverticulum. Tex Heart Inst J 2002; 29:109-12.
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7. Bailey CP, Hirose T, Alba J. Re-establishment of continuity of the anomalous right subclavian artery after operation of dysphagia lusoria. Angiology 1965; 16:509-13.
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9. Jalaie H, Grommes J, Sailes A, et al. Treatment of symptomatic aberrant subclavian arteries. European Vac Endovasc Surg 2014; 48:521-26.
10. Regina DL, Prouse G, 1 Mongelli F, at all. Two-step treatment of dysphagia lusoria: robotic-assisted resection of aberrant right subclavian artery following aortic debranching. European J Cardio-Thoracic Surg 2020; 58: 1093-1094.
11. Knight GC, Codd JE. Anomalous right subclavian artery aneurysms. Report of 3 cases, with a review of the literature. Tex Heart Inst J 1991; 18:209-18.
12. Saeed G, Ganster G. Arteria lusoria aneurysm with truncus bicaroticus. Surgical resection without restoring blood supply to the right arm. Tex Heart Inst J 2010; 37:602-607.

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